Medical Release Form

Function: ______________________________________________________________________________

Player's Name: _____________________________________________ U. S. Citizen Yes_____ No _____

Address: ______________________________________________________________________________

City: _________________________________________ State: ________________ Zip: ______________

Birthdate: _____________________ Sex: ______ Social Security Number:___________________________

Parent's Home Phone: ( _____ )____________________ Work Phone: ( _____ )______________________

Emergency phone number other than Parent/Guardian

Name: _______________________________________ Phone: ( _____ )____________________________

Primary Medical Insurance Company: _________________________________________________________

Policy number: __________________________________________________________________________

Known allergies or other pertinent medical information: _____________________________________________

______________________________________________________________________________________

Recognizing the possibility of physical injury associated with soccer and in consideration for USYS/USS and its affiliates accepting the registrant for its soccer programs and activities (the "Programs") I hereby release, discharge and/or otherwise indemnify USYS/USS, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. My child has received a physical examination by a physician and has been found physically capable of participating in the Programs.

Therefore, I grant ________________________________ and/or __________________________________
permission to act as my surrogate for my child in the area of obtaining medical treatment by a doctor of medicine or dentistry. I also assume the financial responsibility for any medical treatment for my child.

Signature of Parent/Guardian:_______________________________________ Date: ____________________

Subscribed and sworn to me this Day of 20

Signature My commission expires